25A-070 (2) ' oQ�t1/UdP�0
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DEPARTMENT OF BUILDD\TG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 s �`
WORKER'S COMPENSATION INSURANCE A i 'r AVTT
(Ii censeelpermi tt ee)
with a principal place of business/residence at:
(phone#)
(strcct/ci ty/stafrizi p)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Nu.mbcr) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compare}/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach add-Goml shoot ifmccssuy to include iafotma on pertaining to au ooc�raciors)
I am a sole proprietor and have no one worming for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while homeowners who employ persom to do maiatc=Lcr,omstrucUoa or repair work on a dwelling of
not morn than throe units in wtuch the homoowucr resides or on the grounds apVaexnant thencto ace not generally coandcrcd to be
employers uadcr tho worker's oompcm4on Act(GL152,sa 1(5)),application by a homeowner for a license cc Permit may evidence the
legal ctatna of an employer under the Workeet Compemation AcL
I uadrntsad th:z a oopy of this ru t-t may be forwarded to the Dctxutmcur of Industrial Amides&Offioo of rnsiusnca for the
covaYge vaificatioa and that failure to secure coverage under scctioa 25A of MGL 152 can lead to the imposition of criminal peaalties
oomisting of a fine of up to S1,500.00 attdlor i np isoa of up to one year and civil pcaaltia in the form of a Stop Work Ord,and a
firm of 5100.00 a day against tree.
a For dep,rtmc�al rase only
_ Permit NumbeT
( Lot#
>
�e
ture of Li ermtiee
Version 1.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(740 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes......❑ No......❑
SECTION;11-OWNER AUTHORIZATION -TO BE,COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorized 11- 00 1 to act on
my behalf, irk all matters,re ive t rk authorized by this building permit application.
Sigrrature of Owner Date -
l• , as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
-----------------
Print Name - --- -- -------
Signature of Owner/Agent Date
SECTION i12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
SECTION 13 -WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152,§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9-,PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
%XAWjsW A:
_�— Not Applicable ❑
Name(Registrant):
Z 2.42 Registration Numb re
Address / C
Expiration Date
Signature Telephone
92 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
Versionl.7 Commercial Building Permit May 15,2000
7. Water Supply(M.G.L. c.40, §54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone: Outside Flood Zone ❑ Municipal ❑ On site disposal system ❑
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
s
Version 1.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC`FEET.OF ENCLOSEb SPACE
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing
❑ ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
❑ Accessory Building[ ] Repairs [ ]
' 6
JA
SECTION'5 - USE GROUP AND'°�CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly 10 A-1 ❑ A-2 ❑ A-3 ❑ 1A �— ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION`6 BUILDING HEIGHT AND AREA
O� I EUSE ONLY
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION y_ .
Floor Area per Floor(sf) St Y
1st 2nd _
3,
3'd
nd
2
pry„
3 d 4th
4th
a�
a
Total Area (sf) Total Proposed New Construction (sf) y ,<,.•,
, • .,,.
Total Height(ft)_ x
'
Total Height ft --------------------
R.l
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Northampton
OV Department u t
ain Street
��'� 00 100 Wa Well vii a
a 9ortha pto , MA 01060 1iet pf t u
S� one 4 0 124 Fax 413-587-1272 PI6t7ySite lan�s'�`
APPLIC TI ON T, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
P OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
This section to be ebmple ed by office
1.1 Property Addres
'Map `Lot � Unyt
i ll
Zone -Overfay Dtstrict ��
EIm St. District CB Dstricf'
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
lC>>(J✓- / �. AIL,
Name(Print) "�) Current Mailing Address:
L 42
Signature / Telephone
2 2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature ephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS> 6
Item Estimated Cost (Dollars)to be Official Use Only
completed by ermit a licant
1. Building (a) Building Permit Fee
G
2. Electrical (b) Estimated Total Cost of
Construction from 6,
3. Plumbing Building Permit Feed,
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: 3— /1 / Date Issued:
Signature: ' ,
Building Commissioner/Inspector of Buildings Date
BAIin AVE ' BP-2003-1177
GIs#: COMMONWEALTH OF MASSACHUSETTS
k 25A-070 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-1177
Project# JS-2003-1839
Est. Cost: $2500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Edward T Corbett 119488
Lot Size(sq. ft.): 5270.76 Owner: PHYLBORN LEE
Zoning: URB Applicant. Edward T Corbett
AT. 18 HUBBARD AVE
Applicant Address: Phone: Insurance:
1 TERRACE VIEW (413) 584-2546
EASTHAMPTONMA01027 ISSUED ON.
TO PERFORM THE FOLLOWING WORK.REMOVE GARAGE ROOF AND REPLACE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature: _ Fee
Type: Receipt No: Date Paid: Check No: Amount:
Building 6/19/2003 0:00:00 87673540955 $25.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Building Commissioner-Anthony Patillo